Mental Health development in Brazil: From institutionalization to deinstitutionalization in Brazil
Prof.Dra.Rossana Maria Seabra Sade – Universidade Estadual Paulista (UNESP), post doctoral in Trieste -Mental health department. [email protected]
ABSTRACTPsychosocial care, the current model of mental health care in Brazil, recommends replacing the asylum and hospital-centered model for a coordinated care network, community and territorial based services and actions, which involves interdisciplinary and intersectoral work, linking the meaning of mental health to the concepts of citizenship, leadership and quality of life. Such changes have repercussions on concepts and practices in mental health, the organization of services, training and development of professionals. This article not only presents a brief history of the mental health and psychiatric reform in Brazil, but also shows the current configuration of the mental health care network in the country. It will also discusses some issues of the organization of this network of services that may interfere and hinder the consolidation of the community and territorial based care and psychosocial rehabilitation model, pointing out gaps of Brazilian policies to eradicate asylums and institutions, and to implement actions and strategies integrated into the territory. The study points to the importance of a strong network of care, and ends by presenting current challenges to the consolidation of psychiatric reform in Brazil.
Key-words: Deinstitucionalisation. Psychiatric Reform; Mental Health Center. Psychosocial Rehabilitation.
The first Brazilian psychiatric hospitals emerged in the late nineteenth century as corrective assistance. In 1890, under the public administration, the Medical-Legal Assistance for the Insane was created with the characteristics of an asylum, which remained an exclusionary assistance for decades, forming asylum ghettos, in which social actors with psychological distress were confined (BORGES; BAPTISTA, 2008).
Only starting in the 1970s, were experiments made to changes in mental health care, guided in therapeutic communities and subsequently in the community model, substituting the psychiatric hospital model. These changes were driven by the proclamation of the 1988 Constitution, which created the Public Health System (PHS), where the institutional conditions for the deployment of new health policies were established. The PHS ensures full, universal and free access to the entire Brazilian population.
In relation to mental health, the PHS provides for the implementation of new policies, according to the global reform of psychiatric care and the recommendations of the Pan American Health Organization (PAHO), included in the Charter of Caracas (1990) (BRAZIL , 2005). The Ministry of Health gradually redirected the resources of a substitute model for psychiatric care, creating mental health services in community care with territorial coverage, and established criteria for humanization hospital network specialist. All these movements will solidifying the proceedings of the Brazilian Psychiatric Reform, where the Italian psychiatric reform that occurred in the 1960s designed by Franco Basaglia is the main reference.
The flag for the Brazilian Psychiatric Reform is deinstitutionalization; its historical course can be understood in phases: from 1992 to 2001, the implementation of strategies of deinstitutionalization began, with experiences of humanization, control of hospitalization, financing new replacement services and expansion of the outpatient mental health network. In 2001, the Law 10.216, known as Paul Delgado, was adopted after twelve years of debate in the Brazilian National Congress. This Act provides for the protection and rights of social players with psychological distress and social reintegration.
In the last two decades, the social policies implemented by the Brazilian government has expanded the mental health network, shifting the focus of psychiatric hospitalization, with its logic of exclusion and violence, to community services on a territorial basis, which seek to promote and encourage the autonomy and the reconquest of citizenship rights, bringing a gradual reduction of psychiatric rooms, with the expansion of a community-based network outside the hospital.
The diversity of activities and services cover different aspects of the life of the social player, such as: promotion and prevention through action in primary health care service; therapy and rehabilitation conducted by the Centers for Psychosocial Care; leisure and culture at the Community Centers; work and income in income generating and solidarity economy projects developed by associations and cooperatives; and housing through therapeutic residences. All of these actions could be expanded if funding for mental health were concentrated, however federal investments today are divided with both public and private hospital network.
Law 10.216 prohibits the construction of new psychiatric hospitals and the hiring of public service rooms in private units of this type. Thus, the admission will only be indicated when extra-hospital resources prove insufficient. However, there is a contradiction and a constant struggle between the actions and that which determines the legislation. We have few Psychosocial Care Centers (PCCs) open twenty-four hours; social players in crisis during the night and weekends are referred to general hospitals, which are outfitted just for crisis intervention and services are not sufficient for fulfilling the demand, the general hospital ends up working in many cases, as the gateway to the psychiatric hospital.
The law touts the reduction of posts in public psychiatric hospitals, which is happening, as we can see from the blue line in Figure 1 below. However, this reduction does not represent real data, in the extent that there is a substantial increase in the private system, which hosts social players through the PHS. If we had strong public services, the structure of the private network would have a limited place in the Brazilian scenario.
- Hospital spending - Extra-hospital spending
Figure 1 -Resources for psychiatric hospitals and extra-hospital services between 2002 and 2011. The federal government is increasing the investments in extra-hospital services and at the same time decreasing the investments in hospital services. (Mental Health data 10 - BRASIL, 2012).
DESCRIPTION OF MENTAL HEALTH NETWORK IN BRAZIL
a) Psychosocial Care Centers (PCC)
The Psychosocial Care Center is one of the substitute services for mental health care. This substitutive network to the Psychiatric Hospital serves to: provide daily clinical care, thus avoiding admissions to psychiatric hospitals; promote social inclusion of social players in intersectoral action; and regulate admission to the mental health care network. Function is therefore par excellence and PCCs organize the care network for people with psychological distress in municipalities. The PCCs are the strategic articulators of this network and the mental health policy in the territory.
Municipal health services are an open community, offering daily service to social players with severe and persistent mental suffering, performing clinical care and social rehabilitation through access to work, leisure, exercise of civil rights and the strengthening of family ties and community. The designs of these services seek a social support network, focused on the individual and his uniqueness, history, culture and everyday life.
The population profile of the municipalities is a major criteria for the planning of mental health care network in cities. The current policy provides for the deployment of different types of PCC:
PCC I - Mental health care service in cities with population of 20,000 to 70,000 inhabitants. Daily open from Monday to Friday (morning and afternoon) or part time daily;
PCC II - Mental health care service in cities with population of 70,000 to 200,000 inhabitants. The daily service is from Monday to Friday (morning and afternoon) or part time daily;
PCC III - Mental health care service in cities with population over 200,000 inhabitants with 24 hour service;
PCC alcohol and drugs - Service specialized for users of alcohol and other drugs in municipalities from 70,000 to 200,000 inhabitants. Daily service is from Monday to Friday (morning and afternoon);
PCC AD III - For users of alcohol and other drugs in cities with population above 200,000 inhabitants, with 24 hour service;
PCC i - Specialized service for children, adolescents and young people (under 25) in municipalities with population above 200,000, with a daily service (morning and afternoon) or part time daily;
According to updated figures from the Ministry of Health, in Brazil today there are 822 PCC I; 431 PCC II; 63 PCC III; 272 PCC AD and 149 PCCi and 5 PCC AD III, a total of 1742 services. (Mental Health data 10 - BRAZIL, 2012).
Table 1 - evolution of the different types of PCCs
PCC I and II are open Monday to Friday, for twelve hours; in the evenings and weekends, the service is up to psychiatric emergency rooms at general hospitals. Social players must remain seven days and the presence of a family member is allowed. When a person is discharged, he/she is referred to a PCC. The treatment may be in: intensive (daily), semi-intensive (once a week), or non-intensive (once every 15 days).
Figure 2 - Expansion of PCCs through time (Brazil, 1998 - 2011) (Mental Health data 10 - BRASIL, 2012).
It can be seen in the chart above, a gradual expansion of psychosocial care services network, although Brazil is still in the beginning of this process. However, some considerations can be made regarding the form of the organization of services: PCCs are divided by the number of inhabitants per municipality and the level of complexity of cases treated, as stated above. In this form of organization, for small municipalities with less than 20,000 inhabitants to have care, they must proceed to the PCC in the nearest town, causing an overload during consultations. The same happens with the consultation of more severe cases, which are forwarded to the larger cities, which creates an overload for service.
Another point that deserves to be discussed is that the guidelines for the implementation of mental health services predict the proportion of a PCC per 100 thousand inhabitants, as we analyze in Figure 3.
However, in addition to regional differences, which can be seen on the map below, the division of the service ends up fragmenting financial, material and professional resources, reducing twenty-four hour service, as can be seen in Table 1, the disproportion of PCC I and II with 12 working hours in relation to the PCC open twenty-four hours (PCC III).
It is noteworthy that, in Brazil, the PCCs III are found only in a few cities, and there are still many psychiatric hospitals with units closed with bars for chronic patients. There are, in general, no strong services to receive those in crisis, so the social player is brought to the general hospital, and later to psychiatric hospitalization. Also the involvement of technicians, family and society in general is very low.
The PCCs should be unified and give adequate coverage to the population without the current population divisions, remaining with the doors open 24 hours every day of the week. Thus, it becomes clear that changes are needed in the Brazilian legislation.
Figure 3 - Increasing of Mental Health Centers in 1/100,000 hab proportion from 2002 to 2011 in different regions of the country (Mental Health data 10 - BRAZIL, 2012). The graph shows the major increase of Mental Health Services in the South and Northeast regions of Brazil, especially from 2006 to 2011.
Coverage Maps 2002-2011
Coverage Map of Cities with Psychosocial Care Centers (PCCs) from 2002 to 2011. Scale in blue indicates the coverage of cities (the darker the better coverage). (Mental Health data 10 - BRAZIL, 2012).
b) Integrated Care Beds
All resources of hospitality and night shelter of the mental health care network (beds in General Hospitals, PCCs III, general emergencies, the Hospital Service Reference for Alcohol and Drugs) are considered Integrated Care Beds in Mental Health when articulated in network - may be associated with psychiatric beds in small hospitals, when they exist.
These beds must offer the full care to the social player in crisis and should be articulated in dialogue with other reference devices.
The perspective is that this network of integrated care beds, to the extent of its expansion, and the expansion of all open mental health networks, present themselves as a substitute for conventional hospitalization in psychiatric hospitals. To do so, we need investment managers in regulation: the integrated care beds in mental health are an essential component of the gateway to the services network and an effective mechanism for ensuring accessibility. (BRAZIL, 2012).
Figure 4 - Reduction of beds. Different from other countries, the Brazilian law proposed a gradual reduction in the number of beds. The reduction of admissions is not significant because judiciary and clinical admissions are still possible in psychiatric hospitals
c) Therapeutic Residential Services - TRS
They are homes located in urban areas, and organized to meet the housing needs of people suffering from mental disease, whether institutionalized or not. The number of patients can vary from one individual to a small group of up to eight people. Each home includes a professional who acts as a support. Besides this professional, the house has the support of an interdisciplinary team of reference which can be the closest PCC or professionals in primary health care service. There are 625 houses with 3,470 residents in 2011, according to figure 5 below.
The therapeutic support considers the uniqueness of each of the residents, and not just projects and actions based on the collective. Monitoring a resident continues, even if he changes his address or eventually be hospitalized. The process of psychosocial rehabilitation strives to include the social player in the network of services, organizations and social relations of the community. In other words, the insertion in a TRS is the beginning of a long process of rehabilitation, which should seek progressive social inclusion.
The social player with psychological distress, with a long history of psychiatric hospitalization, loses their identity, their right to freedom and live in their own home. According to Saraceno (1999), the history of psychiatry is a story of closed, isolated and more or less guarded mansions. Reflecting on "ways of life", the question that arises is: how to drive this paradigm to recover the lost history of these residents, which was expropriated by the asylum culture?
It is not enough to just take them to a home. The challenge lies in everyday homes and therapeutic homes. And yet: how to ensure there is no reproduction of the diffuse asylum? To Dell'Acqua (2011), this term means a condition in which people, although not institutionalized, have difficulty living their dimension of citizenship, remaining in a dimension of loss, on the outskirts of living, reproducing the same asylum dynamics.
Figure 5 - Increase of therapeutic residences from 2002 to 2011 (Mental Health data 10 - BRAZIL, 2012).
d) Back Home Program - BHP:
The Back Home Program was established by the Federal Law 10708 of July 31, 2003. It standardizes the Psychosocial Rehabilitation Assistance and is a benefit for the social players with a long history of hospitalization, aiding in the process of social inclusion. It is assistance paid to the beneficiary himself for one year and may be renewed if necessary. There were 3,961 BHP beneficiaries in the country in 2011 (BRAZIL, 2012).
e) Community centers:
These are living spaces within the community. These centers do not yet receive funding from the Ministry of Health.
f) Basic Health Unit:
According to the Ministry of Health, the Basic Health Units have the responsibility to: develop actions to promote mental health, prevention and care of those with a history of psychological distress, and promote actions to reduce damage to people with needs arising from the use of crack, alcohol, and other drugs, and whenever necessary, share with other points on the network. The actions of the Family Health Strategy (FHS) and Family Health Support Centers (FHSC) are referred to in the Basic Health Units.
g) Office in the Street:
The team consists of professionals who work on a mobile basis, offering actions and health care for the homeless population. Within the Psychosocial Care Network, it is the responsibility of the Staff in the Street Office to offer mental health care.
h) Damage Reducing School (DRS):
Schools Gear Damage SUS aim at qualifying the service network, through theoretical and practical training of professionals and population segments of the community that will act in the substitutive mental health care network, offering promotion actions prevention and primary care, whether intra or extramural.
In order to leverage the Brazilian psychiatric reform there are both political challenges as well as those in healthcare. In the healthcare plan the big challenge is training of human resources.
Most new professionals in the network are formed by young people who have not gone through political and ideological struggle process that involved the creation of anti-asylum movement, nor have they lived the intense exchange with emblematic figures of this movement at the international level, such as Basaglia, Foucault, Rotelli, and others, on their visits to Brazil. A good part of these professionals became an adult at a moment in the life of the country in which large flags of political transformation had already become history, a time when the sphere of politics itself began to experience an emptying that has only been stressed since then (BEZERRA JR , 2007).
In this direction, there is consensus among various national and international researchers (ROTELLI, 2008; Amarante, 2008; BUTTI, 2008; Mangia, 2009; Ceccim 2010; YASUI, 2010) that, in addition to the expansion of coverage by networks of mental health services, it is essential to reflect on the needs to consolidate the model and its political, cultural and technical continuity and sustainability. For this, the processes of formation and permanent education, planned and developed alongside, and in accordance with, the principles of the Health System and the community mental health education, become essential to qualify the services and teams, as well as ensure the progress of the psychosocial care model.
For this, it is necessary to articulate the mental health and the training strategies and professional/continuing education development, developed to implement the constitutional directive that gives the PHS the mission to direct the processes of formation of human resources in health.
According to Amarante (2008), the training of mental health workers should include a reflection on the concepts and processes that define what science is, on the notion of paradigm and paradigmatic structures, on the relationship between knowledge and power, on relations between science and history. All new staff must learn and develop deeper critical thinking and more problem-solving skills on the complexity of the human experience. Without structural change, asylum reproduction and traditional psychiatry are bound to be reproduced in substitutive services.
For changes to take effect in fact political power must be constantly questioned as Rotelli (2010) analyzes: "We believed that this was a technical task, but it was political and one must seek and provoke political power." Other issues were present in the Italian case: the review of the relationship with medicine, with public authorities and the whole public policies that favor or disfavor the weakest social groups. Somehow, all of the issues we have faced in this experience; to the present day political and social struggles are constant, therefore if one is not careful, the process reverses: the inertia of power and the power of inertia are strong.
The deinstitutionalization process lies not in cures, but in emancipation, the creation of new models and opportunities, demystifying the madness, by allowing the exercise of citizenship. Deconstructing a knowledge that supported the foundations of psychiatry since the Enlightenment, the notion of madness as alienation, error or danger, could be replaced by the notion of difference, the production of life and subjectivity. Psychiatric models should not simply be limited to the abolition of psychiatric structures, but to the construction of new forms of possibilities, in which the players involved have active participation in all processes of change (ROTELLI, 1990).
In the Brazilian context, however, we still have the presence of psychiatric structures coexisting with the network of services embedded in the community. How can Brazil break from the asylum reasoning and psychiatric institutions still functioning?
According to Sade (2012), it is necessary to close the asylums in Brazil. As long as we have mental hospitals open, we have where to refer those with no place, because the family can not live with that person, the school fails to account for their behavior, society gives them the label of deviant. In psychiatry there is a place for it: the mental hospital. So only by dismantling the psychiatric ward structure and deploying active services with Good Practices is the right to citizenship guaranteed. The struggle for the eradication of psychiatric hospitals and the expansion of funding for mental health in the country will form a network of strong and comprehensive psychosocial care.
AMARANTE,P. Cultura da formação: reflexões para a inovação no campo da saúde mental.In: AMARANTE, P.; CRUZ, L.B. (orgs) Saúde Mental, formação e crítica. Rio de Janeiro: Editora FIOCRUZ, 2008, p.65-80.
BASAGLIA, F. et al - A Instituição Negada. Rio de Janeiro: Graal, 1985.
BEZERRA JR, B. Desafios da reforma psiquiátrica no Brasil. PHYSIS: Rev. Saúde Coletiva, Rio de Janeiro, 17(2):243-250, 2007.
BRASIl. Constituição da República Federativa do Brasil, DF: Senado, 1988.
_______. Lei n. 8182 de 19 de setembro de 1990. Institui o Sistema Único de Saúde. Brasília; DF,1990.
________. Lei N. 10.708- de 31 de julho de 2003. Brasília; DF,2003.
BRASIL, Ministério da Saúde. Secretaria de Atenção à Saúde. DAPE. Coordenação Geral de Saúde Mental. Reforma psiquiátrica e política de saúde mental no Brasil. Brasília,2005.Disponível:<http://fjg.rio.rj.gov.br/publique/media/Relatorio_20anos_Caracas.pdf>. Acesso em: maio de 2009.
BRASIL, Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Coordenação Geral de Saúde Mental, Álcool e Outras Drogas. Saúde Mental em Dados 10. Ano VII, nº 10, março de 2012.
BORGES, F.C., BAPTISTA, W.F.T. The mental health care model in Brazil: a history of policy development from 1990 to 2004 . Cad. Saúde Pública, Rio de Janeiro, 4(2):456-468, fev, 2008.
BUTTI, G. Formação e desinstitucionalização em saúde mental. In: AMARANTE, P.; CRUZ, L.B. (orgs) Saúde Mental, formação e crítica. Rio de Janeiro: Editora FIOCRUZ, 2008, p51-64.
CECCIM, R.B. A educação permanente em saúde e as questões permanentes à formação em saúde mental. Saúde Mental: Os Desafios da Formação, Caderno Saúde Mental n.3, pp.67-90. 2010. Disponível em: http://www.esp.mg.gov.br/wp-content/uploads/2012/10/caderno_SM3_Os_desafios_da_formacao.pdf . Acesso em janeiro de 2013.
DELL' ACQUA, G. & MEZZINA, R. Resposta à Crise. In: A Loucura na Sala de Jantar. Resenha, São Paulo, pp. 53-79. 1991.
DELL'ACQUA. G. Gli anni di Basaglia. In: Laboratorio di filosofia contemporânea di Trieste. Follia e Paradosso: Seminari sul pensiero di Franco Basaglia. Trieste: Edizione E, 1995. p.151-155.
_____________ Entrevista concedida a Rossana Sade. Trieste, 20 fev. 2011.
FOUCAULT,M. História da loucura. São Paulo: Editora Perspectiva,1978.
MÂNGIA, E.F. Formação e educação permanente para produzir boas práticas em saúde mental. Revista de Terapia Ocupacional USP, v. 20, n. 2, p. i-ii, 2009.
MEZZINA, R. Paradigm Shift in Psychiatry: Processes and Outcomes. In: RAMON, S; WILLIAMS, J.E. Mental Health at the Crossroads:The Promise of the Psychosocial Approach. Ashgate, 2005, p. 81-93.
ROTELLI, F. Formação e construção de novas instituições em saúde mental. In: AMARANTE, P.; CRUZ, L.B. (orgs) Saúde Mental, formação e crítica. Rio de Janeiro: Editora FIOCRUZ, 2008, p.37-50.
ROTELLI, F. Desinstitucionalização, uma outra via. In: ROTELLI, F. et al,Desinstitucionalização. São Paulo: Hucitec, 1990.
ROTELLI, F. Trajetória da reforma psiquiátrica Triestina do manicômio ao território. (novembro de 2010) Trieste -Itália: não publicada. Entrevista concedida a Rossana Sade
SADE, R.M.S. Caminhos da desinstitucionalização buscas e conquistas: Um estudo sobre a implantação de residências e Lares terapêuticos infanto-juvenil. Buenos Aires: Asoc. Argentina de Profesionales de Salud Mental -AASM, 2012.
SARACENO,B. Libertando Identidades: da reabilitação psicossocial à cidadania possível. Rio de Janeiro: Te Corá/Instituto Franco Basaglia,1999.
YASUI, S. Rupturas e encontros: desafios da re- forma psiquiátrica brasileira. Rio de Janeiro: Fiocruz: 2010.